Does Anthem Pay for Treatment?

Anthem is one of the leading health benefits companies in the United States, and over 40 million people hold Anthem health plans. Within the state of Nevada, Anthem acts as the licensee for the far-reaching Blue Cross and Blue Shield. Anthem Blue Cross and Blue Shield provides coverage for substance abuse and mental health issues through Anthem Behavioral Health, which offers services through a comprehensive provider network.

The National Survey on Drug Use and Health (NSDUH) reports that over 21 million American adults struggled with alcohol and/or drug addiction in 2014, so millions of people need access to this kind of coverage. Treatment services are varied and may initially seem costly. In the long run, substance abuse treatment can actually save a family money as addiction can be an expensive disease. In fact, addiction costs society over $600 billion every year in costs associated with healthcare expenses, lost wages and workplace production, and criminal justice and legal fees, the National Institute on Drug Abuse (NIDA) publishes. Anthem Blue Cross Blue Shield provides health insurance coverage that can help cover some of the costs of addiction treatment services for residents of Nevada.

Members of Anthem Blue Cross Blue Shield can call the Anthem Behavioral Health hotline provided on the back of the member card to obtain information on services. Substance abuse services may not require a referral for coverage; however, Anthem may ask for preauthorization in order for services to be covered. Substance abuse and behavioral health services do generally require preauthorization before services are rendered (except in the case of an emergency) in order for the services to be covered by Anthem.

By calling Anthem Behavioral Health, members can talk to a clinical care specialist who can help to determine the appropriate level of care and help to obtain, and offer information on how to obtain any necessary preauthorization for coverage. The clinical care specialist can also connect members with providers within the coverage network or with approved outside providers when coverage allows. Generally, a primary care provider (PCP) can help to provide preauthorization for services as well.

Be sure to check that the required preauthorization is complete before obtaining specialty services, such as addiction treatment services, in order to ensure that these services will be covered. Services may be covered partially or in full, depending on the member’s plan and level of coverage.

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Anthem Insurance Explained

There are two main forms of coverage offered by Anthem Blue Cross Blue Shield in Nevada: HMO plans and PPO plans. HMO stands for “health maintenance organization” and generally requires that members stay “in-network” and use providers that are within the Anthem-approved network. The PCP will provide referrals to specialty services within the network of care. A PPO, “preferred provider organization,” is more flexible, allowing members to see specialists “out-of-network” and without a referral.

Keep in mind that out-of-network providers and services are generally only covered at a fraction of the cost and are therefore usually more expensive than in-network providers and services. In-network providers have negotiated a discounted rate with Anthem Blue Cross Blue Shield to provide services to members at a lowered rate, which is why going out of the network to non-contracted providers can be more expensive and incur more out-of-pocket fees.

Within Anthem HMO and PPO plans, there is also a range of coverage, from bronze to platinum. Bronze plans typically have the lowest monthly premium costs; however, deductibles (the amount of money paid out before services are covered) and maximum out-of-pocket (an annual maximum amount beyond covered services that is not to be exceeded) expenses are usually higher. Deductibles and annual out-of-pocket maximums go down with silver, gold, and platinum coverage as monthly premiums go up respectively. Copays (the amount paid at time services are rendered) may also be higher with bronze plans than they are with platinum plans. Members may also have co-insurance, meaning that they have more than one insurance plan, and this can be used to help cover addiction treatment services as well.

Anthem Blue Cross Blue Shield offers minimum coverage plans for individuals under the age of 30 or those who meet a hardship exemption. These plans have limited coverage and may be inexpensive to maintain, only offering coverage in the event of a medical emergency (catastrophic health plan).

The Affordable Care Act (ACA) requires that addiction and mental health services be covered by health insurance at the same rate as other medical and surgical services. Substance abuse and mental health issues fall under the “ten essential health benefits” that must be covered, at least in part, by all insurance plans sold on the federal Marketplace.

Individuals may qualify for discounted health insurance through Anthem Blue Cross Blue Shield and the health insurance Marketplace, which may provide coverage at a reduced rate for qualified individuals. Anthem Blue Cross Blue Shield also provides options for Medicare coverage for senior citizens over the age of 65.

Amount of Covered Services

Typically speaking, treatment services will be covered at a percentage. For example, a plan may cover 80 percent of services, and the covered member is expected to pay for the other 20 percent out of their own pocket after the deductible is met. There is also the maximum out-of-pocket limit, and once this total is reached, services are covered at 100 percent for the remainder of the year.

Generally, bronze plans cover services at around 60 percent, silver at 70 percent, gold at 80 percent, and platinum at 90 percent. Members are responsible for covering the remaining percent up to their annual out-of-pocket maximum is reached. Some services, such as therapy appointments for instance, may have a certain number of sessions covered in a year. Inpatient services may be covered for specific amounts of time as well. Each individual plan will vary on plan type (HMO vs. PPO) and level of coverage (bronze, silver, gold, or platinum). Plans and coverage can also be different from state to state.

An Anthem Blue Cross Blue Shield clinical care specialist can help members to determine exactly what may be covered by their specific insurance plan and how best to maximize coverage for addiction treatment services. Treatment facilities also generally have highly trained professionals on site to help families navigate insurance coverage and how to use it to pay for necessary treatment services. Treatment facilities also typically offer resources on how to cover the costs associated with treatment for families and individuals.

NIDA estimates that addiction treatment services can save around $12 for every $1 spent when taking into account legal, criminal, and healthcare costs associated with the disease of addiction. Experts agree that getting help for addiction is more cost-effective than long-term drug abuse and addiction.

The financial aspect of treatment shouldn’t be a barrier to getting help, as various options exist to make the process of paying for care more manageable. An addiction treatment specialist can help families learn how to budget and pay for specialized care and also how to maximize Anthem health insurance coverage when paying for services in Nevada.